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WALGREEN CO.
DSH430016 AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430016
Entity Address
1325 S. CLIFF AVE.
SIOUX FALLS, SD 57105
Medicare Provider Number
430016
Participating Start Date
9/18/2008
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05243
2605 W 12TH ST
SIOUX FALLS, SD 57104
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Steve Petersen, Vice President of Pharmacy
(605) 322-8313
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2020
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